Group Life Insurance

Life insurance is an integral part of most employee benefits packages. When provided by an employer, employees appreciate the value of life coverage and the additional security it provides to their families.

Employers have a wide variety of optional plan designs to customize a Group Life plan. Optional coverages include Voluntary Life insurance, Supplemental Life coverage, Accidental Death and Dismemberment policies, and Dependent Life insurance. The premium paid for Group Life is generally a business deduction, and this stand-alone contract is usually less expensive than the life coverage provided with medical insurance.

Group Life Insurance Quote Request

Please take a moment to fill out the form below and one of our local insurance agents will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Required fields.

General Information
Legal Name of Business:
Contact Name: *
Address:
City:
State:	Zip:
Business Phone: *	Fax:
Best Time To Call:	AM   PM
E-mail Address: *

Type of Business
Type of Business:
No. of Full Time Employees:	No. of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Life Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:	Premium Amt: $
Years Insured:
Please give a brief description of your current Group Life plan:

Benefits Desired
Amount of Life Insurance Per Employee:		Select One $5,000 $10,000 $25,000 $50,000 $100,000 $250,000 $500,000 $1 million Other Amount
Dental Coverage:	Yes No	PPO Option:	Yes No
Disability Insurance:	Yes No	HMO Option:	Yes No
Optional Pregnancy Coverage:	Yes No	Supplemental Accident Coverage:	Yes No

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Zip Code	Sex	Dependent Status
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
			Male Fem	Emp. Only Emp. + Spouse Emp. + Child Emp. + Family
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.

Additional Comments or Questions

Enter Security Code:

Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.